Hi @BillFawcett I can hear you in Wollongong for the @AAGBI webinar! Covid-19 dilemmas. 1000 signed up. @doctimcook Sarah Armstrong. @traumagasdoc Robert Wheeler. Robert Tobin.

Supporting, informing and inspiring.

Quite rightly @BillFawcett states that the crisis is testing every part of us. That we are bombarded with information. And yet we remain resolute.

First up Tim Cook on PPE. Notes concerns of HCW, which started with the poor young Chinese Dr dying. In early studies in China 1/3 of pts were HCW where PPE not universally used.

Severity of HCW illness reduced over the period of measurement in China = PPE works.

Intubation is highest risk aerosol generating procedure. However, if wearing PPE risk is very low.

PPE in two lines:

understand modes of transmission
gloves and aprons are disposable

Transmission = droplets mostly, a few aerosols (not considered large source of transmission), droplets.

Understand the route of transmission, and you can work out the PPE required.

Dispose gloves and apron each time.
Masks, eye protection and gowns can be 'sessional'.

Audience q for hip surgery and PPE: Cook says PHE guidance a little non-specific here. Needs to differentiate respiratory tissue from other tissue.

Cook notes the guidance produced by PHE is similar to WHO and other organisations. But not the same as full suits in China. Doffing procedures are different worldwide. Cook says showering after an AGP is not unreasonable, esp if neck uncovered.

Audience q Cook re uncovered parts of body. Says try and cover as much as you can cover. Washable shoes (and wash them) - no clogs with vents. The more complex PPE = more likely to self-contaminate when doffing. There is strength in simplicity.

Notes many gizmos like sheets and boxes around, but concern that complexity may increase chance of contamination.

Hoods don't tend to be used outside of China, therefore a face shield / visor in addition to just goggles/mask to cover face is good. Reusable equipment is appropriate (decontaminated between use), even if something from the hardware store.

PPE is about reducing risk of infection to HCW. Need to remember all other principles of infection control for patients.

CPR question - currently PHE state that chest compressions are not AGP but other organisations say it is or uncertain. Guidance may be updated between these organisations. If you decide its an AGP then everyone in the room needs aerosol precautions.

Dr Sarah Armstrong next on obstetrics during Covid-19.
Labour analgesia. Emergency Section. Appropriate PPE. What else can we do to prepare?

No evidence that one mode of delivery is better than another in a woman with covid 19 (unless resp compromise). NO evidence that entonox is an AGP, therefore use. Epidural not CI - recommended to decrease risk of GA if need caesarean.

Epidurals in Labour for covid 19 patients. Case by case basis. Check platelets (can get drop in covid 19). Caution with dosing and monitoring.

Don sterile PPE outside of room. Need buddy. Single use trays/grab bags. Verbal consent. Documentation after procedure outside the room. Don't take the pen in!

Emergency caesarean: Familiarise yourself with covid and non-covid theatre. Inform patients that PPE will cause staff delay. GA is AGP. Neonatal resus might be AGP (but low risk). High risk of conversion to GA (failed regional, bleed). Lack of smoke evacuation for diathermy.

Sterile PPE fine for labour epidural.
Emergency caesarean - risk assess for need to wear full PPW. What is the risk of need for GA.

One pragmatic approach:
- in covid positive or suspected: AGP for all cat 1 / cat 2 sections
- cat 3/4 - standard per with FRSM after risk assessment
- ?partners in theatre/labour - many different views

Familiarise yourself with your units policy.

Please note epidural top ups have excessive hypotension during top up. Consider phenylephrine infusion (although this drug may become scare - might have to switch to metaraminol).

Grab bags are handing.
Minimise documentation in theatre.
Consider post-op disposition.

What else can we do? Improve direct communication between obstetricians and ITU. Formulate a joint ITU/obs care plan for covid-19. Notes anaesthetists often the link, may be less available as crisis worsens.

Consider alternatives if shortages occur:

? carbetocin - to avoid oxytocin infustion
? manual epidural top ups
? return to metaraminol and thiopentone
? field medicine - diamorphine, ketamine
? training obstetric trainees for pudendal nerve blocks?

Finally - don't assume every fever = covid19. If it looks like a duck, and walks like a duck, it probably is a duck.

First question - should all parturients be treated as covid positive? Updated guidance coming.

Q re Remi PCA: Don't start using remifentanil PCA if your unit not using is already. (Commits 1:1 midwifery care, might contribute to respiratory compromise).

Instead, encourage epidurals with full patient discussion / informed consent to avoid need for GA.

Q re where to gain consent? In Sarah's place, anaesthetist goes directly to covid theatre and starts donning PPE in order to minimise delay. Consent in theatre.

Epidural consent is in the room, verbally (previously was written).

Suggests to follow advice of individual unit.

Next speaker is @traumagasdoc speaking about social media in the time of covid.

YOU ARE NOT A SOFT INTERLUDE HELGI!!

Helgi notes that social media is an amazing way of connecting people, especially at a time like this, when used wisely.

How can SoMe help?

sharing of information
resources and guidelines
peer support
new ways of working

HI HELGI THANKS FOR THE SHOUT OUT!!

Social media has been incredibly useful to disseminate information during #covid19 on FB, twitter, WhatsApp. Particularly from our Italian colleagues.

Some say this crisis is like a tsunami, Helgi says for him it's more like we're in a water tank, the water is filling up slowly, we need to make sure there's enough oxygen at the top.

Helgi has transitioned to intensive care this week. Hasn't done it for many years. Social media has provided information and peer support for this (as have his colleagues on the unit, others who are also new to the unit).

Main stream media are on social media, looking for stories. Looking for spin and angles on a story. There is a large hunger for anaesthesia / intensive care stories. Great opportunity for our usually low profile specialties to educate the public about our role.

Pitfalls:
photos, places, people, backgrounds
emotional outbursts
major incidents
asking for free stuff
email etiquette
privacy settings

Photos - don't use patients (even if consent, very tricky); get consent from everyone in the photo if it is your team. Don't post pictures of sensitive areas in the hospital. Be careful to not accidentally have a patient list in the far background.

Emotional outbursts - can be powerful but can backfire. Perhaps don't tweet if you're angry or upset, might regret it. Just like emails. (thanks @inquisitiveGyn and @hypoxicchicken for keeping me safe here).

Covid19 is a major incident. Might have high profile cases. Might need media lockdown.

Asking for free stuff is a little tricky. Remember that there are many newly unemployed. NHS workers have protected salaries.

Privacy settings give a sense of security. There's no such thing as a totally secure setting. Be careful. Don't write anything that you would not want to say to someone in real life.

The 'daily mail' test.

How to get yourself out of trouble on social media:

Most of us will get unwanted attention (trolls who write mean things) Best strategy is ignore. Can hide the comment.

What to do if you say something you regret?

Worst thing you can do is ignore.

Best is to delete, apologise, pause, move on.

Helgi's top Social Media Tips:

Be yourself.
Don't be 2D - show us who you are!
Be positive and inclusive.
Don't say anything you wouldn't say to someone's face.

ENJOY!

Thank you Helgi for another great talk. So lovely to hear you this evening.

Q about safety of patient information on work WhatsApp groups. Advice to make sure limit info needed (but know enough to be clear about which patient is being referred to). Everyones phone should be password protected.

Q about SoMe comments which identify hospital. Notes that positive messages usually fine. However, complaining about hospital without going through usual in-hospital channels is not acceptable. The main stream media will leap on negative comments eg around insufficient PPE.

Mr Robert Wheeler next - paed/neonatal surgeon and lawyer. Clinical decision making in pandemic conditions. Common law says that physicians must save life.

We are not accustomed to insufficient resources to treat patients. May be in awful position to accept that arriving patient can't be ventilated, or currently treated patient must be withdrawn to make room.

Who can reliably predict when a particular patients life will end?

Plethora of current outcome tools show that we are not able to be objectively certain of which patient will live and which will die.

Therefore ethicists must wrestle with different subjective choices.

How do we value life greater than an other?

Must provide patients with a comfortable, dignified and pain free death; even if can't provide ventilation during pandemic conditions.

Resuscitation decisions should be individualised. Second opinions.

Clinicians might become infected with the virus during resuscitation.

Weekly temporary ethics counsel has been established in his trust. 24/7 phone advice. Suggests considering this in other trusts.

Ethics council provides support to clinicians to aid decision making when resources are limited, and capacity is reached during a pandemic.

Audience q: who is on the ethical council. 30-40 people in the pool. 3 or 4 pulled. Multidisciplinary. Clinical staff with knowledge of ethics/law.

Rob Tobin now. Legal liabilities during the coronavirus pandemic.

Civil Claims
Regulatory.
Criminal. (doesn't envisage any of these)

Civil claims - drs have a duty of care to the patients. Exercise of that duty is governed by the Bolam test; plus consider Bolitho and Montgomery for the subjective elements.
Context is everything. You can only provide Rx that is available. The law will take that into account.

What treatment is actually available and feasible in the circumstances?

EXPLAIN EVERYTHING IN THE NOTES .

Standards of care:
most will be working in their area, some outside
likely to give rise to claims: Bolam judged against others 'in the same field'
is that fair?
will Bolam be diluted?
rescuer principles may be considered
training and supervision crucial and will be scrutinised

This is usually applied say in a RTA where someone unexpectedly needs to assist. However, might be used in drs working outside usual area during covid19.

Non-covid patients may claim:
delayed elective surgery
examination by phone
blood tests not done
even if limitations are forced by trust wide decisions, each pts needs should be considered to mitigate/avoid harm
consider a trust framework for this .

WRITE IT DOWN!

Notes that although now all we are talking about is covid19, this will pass, notes of the current issues will be read by the judge when making decisions about claims. This will fade from memory!!! (apparently - lets hope so).

Already one judicial review arising from covid involving child with autism and concern around restriction of liberty.

Word of warning about all the new policies. Questions may arise about the lawfulness of such new policies, including discrimination and equality issues.

A claim is inevitable but don’t worry.
The NHS will deal with it.

GMC has coronavirus guidelines. Notes that you should consider what will be best for the individual patient - given available options.

Bottom line is that rescuer principle allows those working outside their scope of practice to be legally protected during the pandemic; and availability of resources is taken into consideration.

Notes that BMA Guidance around coronavirus is very good.

Brief mention about criminal liability:
don't break the law
don't actively bring about a patients death (different to withholding futile or not available treatment)
not criminally responsibly if treatment recommended, but can't be provided if treatment not available

Q - are you breaching patient confidentiality for checking a covid status of a patient you intubated 2/7 ago? A = no.

Q - should we advise patients who come into hospital that they are at increased risk of getting infected by coming in? A - yes you should. Patients must be informed of all risks, however also need to emphasise the safety procedures to keep them safe.

Q - what if patients conceal their coronavirus symptoms? A - if it puts you at risk (not tested) patient might be liable. Can't refuse to treat but can restrict liberty under the regulation.

If anaesthetist believes that waiting list elective surgery isn't as safe or as good as usual (for eg diverted to other facility) it is a requirement to let the patient know this, and they can decide whether to proceed or delay till after covid.

Thank you @BillFawcett and team for a great webinar. Very informative. Similar issues here in Australia. From half a world away - seamless! Good night!